What Are CPT Codes?

How Do CPT Codes Affect Your Healthcare?

CPT codes. Getty Images Credit: Hero Images

CPT (Current Procedural Terminology) codes are numbers assigned to every task and service a medical practitioner may provide to a patient including medical, surgical, and diagnostic services. 

A CPT code looks like a five-digit alphanumeric code with no decimal marks. Most CPT codes consist of 5 numbers. Some are used frequently like 99213 or 99214 (for general check ups). Some CPT codes may have a letter at the end of them, using 4 numbers and one letter.

CPT codes are used by insurers to determine the amount of reimbursement that a practitioner will receive by an insurer when he or she performs that service. Since everyone uses the same codes to mean the same thing, they ensure uniformity.

CPT codes are developed, maintained and copyrighted by the AMA (American Medical Association.) As the practice of health care changes, new codes are developed for new services, current codes may be revised, and old, unused codes are discarded. Thousands of codes are in use, and they are updated annually. Development and maintenance of these codes are overseen by editorial boards at the AMA, and the publications of all the software, books and manuals needed by those who use them bring millions in income (*see note below) to the AMA each year.

It should be noted, however, that uniformity in understanding what the service is, and the amount different practitioners get reimbursed will not necessarily be the same.

For example, Doctor A may perform a physical check up (99396) and be reimbursed $100 by your insurance company. If you went to Doctor B, his reimbursement by your insurance company for that same checkup, Code 99396, might only be $90.

Examples of CPT Codes:

  • 99214 may be used for an office visit
  • 99397 may be used for a preventive exam if you are over 65
  • 90658 indicates a flu shot
  • 90716 may be used for chicken pox vaccine (varicella)
  • 12002 may be used to stitch up a one-inch cut on a patient's arm

Some CPT codes are bundled;  that is, they are used in combination with each other so they actually describe a number of aspects of care.  You can learn more about bundled medical codes here.

If you use Medicare, you'll see CPT codes, but used a bit differently. Medicare uses HCPCS codes (Healthcare Common Procedure Coding System) which are an adjusted form of CPT code.

Matching CPT Codes to the Services They Represent

As patients, our interest in these codes is usually related to our doctors' and insurance billings. Until recently it was difficult to find out what certain CPT codes meant without contacting your insurance company or doctor's office.

You won't find a freely-available comprehensive list of CPT codes because the AMA controls their publication. Groups that have tried to make them available for free to the public have been cited for violations, fined by the AMA and have been forced to remove them from the Internet. Since the AMA developed and copyrights the system, it has a right to make sure access to these lists is paid for. It licenses CPT code lists to groups who wish to publish the codes to make them available to others.

Those groups then charge a fee for access, too.

We patients don't have the large sums of money needed to subscribe to websites or purchase publications that list CPT codes. To make them more accessible to us, the AMA does provide on its website a means for looking up the individual CPT codes you might find on your doctor's bills or EOBs (estimates of benefits).

Where to Find CPT Codes in Medical Records

CPT codes (Current Procedural Terminology) are found and used in various paperwork and documentation as we transition through any healthcare experience. CPT codes cant be used to determine everything from your diagnosis to the cost of your healthcare.

Patient Paperwork - Where to Find CPT Codes

  • As we leave a doctor's appointment, check out of the hospital, or any other medical facility, we are handed paperwork that, to the professionals, is a numeric summary of the services they provided to us. The five character codes are usually CPT codes.

    There are other codes on that paperwork, too. Some may be ICD codes, which may have numbers or letters and usually have decimal points. If you are curious about codes with decimal points, check out ICD codes.

    If you use Medicare, those codes will be called HCPCS codes, but for patient purposes, the codes are the same.

  • When we receive a bill from the doctor, before or after it has been sent to our payer (insurance or Medicare), it will have a list of services. Next to each service will be a 5-digit code. That's the CPT code.
  • When we receive an EOB, Explanation of Benefits, from our payer (insurance, Medicare or others), then it will show how much of each service was paid for on our behalf. Like the doctor's bill, each service will be aligned with its CPT code.

Provider Paperwork - Where Providers Are Using CPT Codes

  • CPT codes directly affect a provider's income. As such, they are very particular about how coding is done, and spend huge sums of money each year in the management of billing and coding. Medical coding is its own career, and can be very lucrative for the right person.
  • After we leave the doctor's office, the billing and coding people submit to our payers a list of the services they provided to us. This may be done by postal mail or fax, but more and more, doctors and facilities are using electronic means to store and transfer this information.

How to Match CPT Codes to the Services They Represent

If you have paperwork that has a CPT code on it, and you want to figure out what that code represents, you can do so in a number of ways:

  • Do a CPT code search on the American Medical Association website. This is a new capability and allows patients to search for a CPT code, or use a keyword to see what the associated CPT code might be.
  • Contact your doctor's office and ask them to help you match CPT codes and services.
  • Contact your payer's billing personnel and ask them to help you.
  • Remember that some codes may be bundled, but can be looked up in the same way.

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